Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level I screening from the State Mental Health Agency in the case of residents without serious mental illness or a related condition for one (#7) of three residents reviewed for PASRR out of 37 sample residents.Specifically, the facility failed to follow the recommendation to re-evaluate Resident #7's PASRR level I screening if the resident's symptoms or behavior did not improve or resolve within 60 days of the screening.Findings include:I. Facility policy and procedureThe Admissions policy, revised March 2019, was provided by the nursing home administrator (NHA) on 3/2/26 at 12:28 p.m. …
F645 citations in Colorado
PASARR screening · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Colorado cites F645 more often than its own record predicts
1.05 times the share F645 takes of citations nationally.
Of every deficiency written in Colorado in 2024, this is the portion that was F645.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F645 findings written in Colorado, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.51% | 0.87× |
| 2024 | 0.67% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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